Disaster Recovery Allowance
Tropical Cyclone Debbie
March 2017
1
Please read this before answering the following questions.
6
The Disaster Recovery Allowance is for people who can
demonstrate they have experienced a loss of income as a
direct result of a disaster.
The Australian Government Department of Human Services
will do regular audits and you may be asked to provide
evidence to support your claim.
For more information
If you are not sure about your claim, or you need more
information, including details about the date you need to
lodge your claim by or if you will be required to provide
documentation to confirm your identity, or other assistance
you may be entitled to, please refer to
humanservices.gov.au/disaster or call us on 180 22 66.
Note: Call charges apply.
7
Do you need an interpreter when dealing with us?
3
Go to 5
Yes
Go to next question
Go to next question
Yes
You may not be eligible for this assistance.
Please call us on 180 22 66.
Do any of the following apply to you?
An Australian citizen
Go to next question
A permanent visa holder
Go to next question
A New Zealand passport holder
Go to next question
Holder of an eligible
temporary visa
Go to next question
For more information on temporary visa subclasses go to
humanservices.gov.au/specialbenefit or call us on 180 22 66.
8
Do any of the following apply to you?
Tick ALL that apply
What is your preferred spoken language?
Live in an affected area
Suburb
Work in the affected area
Suburb
Derive income from the
affected area
Suburb
None of the above
4
What is your preferred written language?
9
5
Do you have a Centrelink Reference Number?
No
Go to next question
Yes
Your Centrelink Reference Number (if known)
You may not be eligible for
this assistance.
Please call us on
180 22 66.
None of the above
This includes an interpreter for people who have a hearing or
speech impairment.
To speak to us in languages other than English, call 131 202.
No
No
Tick the first option
that applies to you
Returning this form
Please return this form to one of the following:
• post your claim form to:
Reply Paid 7815
CANBERRA BC, ACT 2610
or • take your claim to your nearest Department of
Human Services service centre or any Agent.
or • fax your claim form to: 1300 727 760.
Please make sure any accompanying documentation
is also clearly identified with your name.
2
Are you receiving an income support payment or pension
(e.g. Age Pension, Newstart Allowance, Service Pension from the
Department of Veterans’ Affairs or Farm Household Allowance)?
You may not be eligible for this
assistance.
Please call us on 180 22 66.
Have you lost or suffered a reduction in your income as a direct
result of the disaster?
No
You may not be eligible for this assistance.
Please call us on 180 22 66.
Yes
Go to next question
CLK0EM164 170331
EM164.170331
1 of 12
10 Are you 22 years of age or older?
No
Go to next question
Yes
Go to 14
15 Have you ever used or been known by any other name
(e.g. name at birth, maiden name, previous married name,
Aboriginal or tribal name, alias, adoptive name, foster name)?
Please read this before answering the following questions.
Questions 11–13 are to be completed ONLY if you are under
22 years of age.
No
Go to next question
Yes
Give details below
Other name
11 Are you wholly or substantially dependent on another person?
For example, are you living with your parent(s) or guardian(s)?
You are classed as wholly or substantially dependent if you are
dependent on another person (except your partner).
Type of name (e.g. name at birth)
No
Go to next question
Yes
You may not be eligible for this assistance.
Please call us on 180 22 66.
If you have more than 1 other name, attach a separate sheet
with details.
16 Your gender
12 Are you a parent or have a dependent child in you care?
No
You may not be eligible for this assistance.
Please call us on 180 22 66.
Yes
Go to next question
Male
Female
17 Your date of birth
//
13 Is your estimated income greater than $6403?
No
You may not be eligible for this assistance.
Please call us on 180 22 66.
Yes
Go to next question
18 Your principal place of residence
14 Your name
Mr
Mrs
Postcode
Miss
Family name
Ms
Other
19 What date did you start living at this address?
//
First given name
20 Was this your principal place of residence during the disaster?
Second given name
No
Go to next question
Yes
Go to 23
21 What was your principal place of residence during the disaster?
Postcode
22 When did you live at this address?
From
To
//
EM164.170331
2 of 12
//
23 Do you have a temporary or postal address?
29 Are you an Australian citizen who was born in Australia?
No
A postal address can be a PO Box.
No
Go to 25
Yes
Give details below
You will need to provide proof of your
Australian residence status (e.g. citizenship
papers, passport or other documentation).
Go to next question
Yes
Go to 35
30 What is your country of birth?
Postcode
This address is:
Tick ONE box only
Temporary address
Postal address
31 What is your country of citizenship?
Go to next question
Go to 25
Date you became an Australian citizen
Australia
//
24 What date did you start living at the address given at 23?
Other
//
Go to 34
Country of citizenship
25 IMPORTANT
32 What is your current type of visa?
This payment can be paid for a maximum period of 13 weeks
dependent on your circumstances. Before the end of the
13 weeks we will contact you to advise of the required steps
that must be taken if you require further assistance. Please
ensure your contact details are always up to date.
New Zealand passport
(Special Category visa)
Permanent
Temporary
How can we contact you?
Unknown (e.g. arrived
on parent’s passport)
Phone number ()
To help us serve you better, please provide your mobile number
Mobile phone number
Note: This mobile number will automatically be subscribed
to our electronic messaging service. We may use this mobile
number to contact you. For Terms and Conditions, go to
humanservices.gov.au/em
Go to next question
Yes
Go to 28
Go to next question
Go to 35
Visa sub class
Date visa granted
//
34 Are you subject to an Assurance of Support agreement?
A person is not eligible to receive Disaster Recovery
Allowance if they are subject to an Assurance of Support
agreement.
27 When did you return to Australia after the disaster?
//
28 Please read this before answering the following questions.
To receive the Disaster Recovery Allowance, you must be an
Australian resident living permanently in Australia.
‘Permanently’ means you normally live in Australia on a
long-term basis. Holidays or short trips outside Australia
would not affect this.
For more information on residency, go to
humanservices.gov.au/residencedescriptions
Are you living in Australia permanently?
No
Yes
EM164.170331
Go to next question
33 Your visa details on arrival
26 Were you in Australia when the disaster occurred?
No
Go to 35
3 of 12
No
Go to next question
Yes
What is the name of your Assurer?
35 Please read this before answering the following questions.
39 Has your partner ever used or been known by any other name
(e.g. name at birth, maiden name, previous married name,
Aboriginal or tribal name, alias, adoptive name, foster name)?
We need to know if you have lived in any countries other
than Australia from birth through to the present. ‘Lived’
means where you/your family made your home or spent a
long period of time – it does not include places you visited.
Except for short trips or holidays, have you EVER lived outside
Australia?
Go to next question
Yes
Give details below
Other name
No
Go to next question
Yes
If you were born outside Australia, include the country
where you were born.
Include the period(s) you have lived in each country.
Do NOT include short trips or holidays.
Type of name (e.g. name at birth)
If your partner has more than 1 other name, attach a separate
sheet with details.
1 Country of residence
//
From
No
40 Your partner’s gender
//
To
Male
2 Country of residence
Female
41 Your partner’s date of birth
//
From
//
To
//
If you require more space, attach a separate sheet with details.
42 Date you became partnered
//
36 Do you have a partner?
No
Go to 46
Yes
Go to next question
43 Does your partner live at the same principal place of residence
as you?
37 Does your partner have a Centrelink Reference Number?
No
Go to next question
Yes
Your partner’s Centrelink Reference Number (if known)
No
Go to next question
Yes
Go to 45
44 Your partner’s principal place of residence
38 Your partner’s name
Mr
Mrs
Miss
Family name
Ms
Postcode
Other
45 Do you give permission for your partner to discuss details about
your claim?
First given name
No
Yes
Second given name
46 Do you (or your partner) have dependent children under 16 years
of age in your care?
Note: There are no additional payments for dependent
children. If you (or your partner) currently receive Family Tax
Benefit you may need to revise your income estimate.
EM164.170331
4 of 12
No
Go to 48
Yes
Go to next question
47 Give details below of your (or your partner’s) youngest
dependent child
49 Are you self-employed?
No
Child’s family name
Yes
Go to next question
The income you receive from self-employment
must be included at question 70 and question 74.
Child’s given names
50 What date did you stop working or first incur a reduction in
your income as a result of the disaster?
Other name this child has been known by
//
Child’s date of birth
Child’s gender
//
Male
Female
51 Which one of the following reasons best describes why you
have suffered a loss of income?
Are you the principal carer of this child?
Yes
No
Workplace damaged or destroyed
I am unable to get to my usual workplace
Is there a shared care arrangement in relation to this child?
Yes
No
Cancelled bookings/orders
What is your percentage of shared care?
Cancellation of planned tourism events
%
Loss and/or damage to stock
Do you (or your partner) receive Family Tax Benefit for this
child?
Yes
No
Injury suffered
Loss and/or damage of machinery/tools
Loss of necessary utilities
48 Provide details of your usual work (e.g. employment,
self-employment, sub-contracting, farming).
Lack of staff/workers/contractors
Employer’s name, business name or farm name
Unable to import/export products
Other
Australian Business Number (ABN)
Address
52 Explain why you stopped work in further detail
Note: If you did not stop working as a result of the disaster you
may not be eligible for this assistance. Call us on 180 22 66.
Postcode
Phone number
()
What industry are you employed in?
For example: a person working in the banana industry
should write: Agriculture – banana industry, a clothes shop
assistant should write: Retail – clothes.
Is this work
Full-time
Other
Part-time
Seasonal
Casual
53 Are you on planned leave from your workplace?
Give details
Was your income from this employer impacted as a result of
the disaster?
No
Go to 57
Yes
Go to next question
54 What type of leave?
For example: annual leave, sick leave, maternity.
Yes
If you have more than one employer, attach a separate
sheet with details.
You must answer questions 48 to 57 for each employer.
EM164.170331
No
5 of 12
55 Start date of leave period
End date of leave period
//
62 Do you receive the National Enterprise Incentive Scheme (NEIS)
Allowance?
//
56 Is this paid leave?
No
Go to next question
Yes
You may not be eligible for this assistance.
Please call us on 180 22 66.
No
Yes
63 Do you have an interest in any real estate in and/or outside
Australia (other than your principal place of residence)?
57 Have you returned to work after the disaster?
No
Go to 65
No
Go to next question
Yes
Go to next question
Yes
Date you returned to work after the disaster
64 Do you receive an income from the properties (i.e. rental/lease
//
income)?
No
58 Do you have an income protection policy?
No
Go to 62
Yes
Name of insurance company
59 Have you lodged a claim or intend to lodge a claim for the loss
of income?
No
Go to next question
Yes
Go to 61
Yes
Go to next question
Attach a copy of your tax return for the
previous year when lodging this claim.
The income you receive from rental properties
must be included at question 70 and question 74.
65 Do you own any shares, options, rights, convertible notes or other
securities LISTED on an Australian Stock Exchange (e.g. ASX,
NSX, APX or Chi-X) or a stock exchange outside Australia?
Include shares traded in exempt stock markets.
Do NOT include:
• managed investments
• investments purchased with a margin loan.
60 Explain why you have not lodged a claim
No
Go to next question
Yes
Give details below
Attach the latest statement for each share
holding.
Go to 62
The income you receive from these investments
must be included at question 70 and question 74.
61 What was the outcome of the claim?
Pending decision
1 Name of company
Rejected
To be lodged in future
Granted
Number of shares or
Security code (if known)
other securities
Give details below
Has a waiting period been applied?
No
Yes
Country if not Australia
Waiting period end date
%
//
If you have more than 1 investment, attach a separate sheet
with details.
Have payments commenced?
No
Yes
Attach a copy of the most recent letter
or statement from the insurance policy
provider showing payment details.
Any income you receive from this insurance
policy must be included at question 74.
EM164.170331
Your share
6 of 12
66 Do you own any shares, options or rights in PUBLIC companies
NOT Listed on a stock exchange?
67 Do you have any managed investments in and/or outside
Australia?
Do NOT include:
• managed investments
• investments purchased with a margin loan.
No
Go to next question
Yes
Give details below
Include:
• investment trusts
• personal investment plans
• life insurance bonds
• friendly society bonds.
Do NOT include:
• conventional life insurance policies
• investments purchased with a margin loan.
APIR code – is commonly used by fund managers to identify
individual financial products.
Attach the latest statement detailing your
share holding for each company (if available).
The income you receive from these investments
must be included at question 70 and question 74.
1 Name of company
No
Go to next question
Yes
Give details below
Attach a document which gives details
(e.g. certificate with number of units or
account balance) for each investment.
Type of shares, options or rights
The income you receive from these investments
must be included at question 70 and question 74.
Number of shares, options or rights Current market value
$
1 Name of company
Your share
%
Name of product
(e.g. investment trust)
If you have more than 1 investment, attach a separate sheet
with details.
Number of units
Type of product/option
(e.g. balanced, growth)
APIR code (if known)
Currency if not AUD
Current market value
$
Your share
%
If you have more than 1 managed investment, attach a
separate sheet with details.
EM164.170331
7 of 12
68 Please read this before answering the following question.
69 Do you have any money invested in, or do you receive income
from, any other investments or sources, not declared elsewhere
on this form?
An income stream product is a regular series of payments
which may be made for a lifetime or a fixed period by:
• a financial institution
• a retirement savings account
• a superannuation fund
• a Self Managed Superannuation Fund (SMSF)
• a Small APRA Fund (SAF).
Types of income streams include:
• account-based pension (also known as allocated pension)
• market-linked pension (also known as term allocated
pension)
• annuities
• defined benefit pension (e.g. ComSuper pension, State
Super pension)
• superannuation pension (non-defined benefit).
Include:
• all investments from outside Australia (including
superannuation) not declared elsewhere on this form.
Do NOT include:
• income from real estate in or outside Australia, private
trusts, private companies or business
• social security payments
• an account used exclusively for funding from the National
Disability Insurance Scheme.
Go to next question
Yes
Give details below
Go to next question
Give details below
You will need to provide proof of your income
from other investments and sources.
Do you receive income from any income stream products?
No
No
Yes
The income you receive from these investments
or sources must be included at question 70 and
question 74.
You will need to obtain a schedule from your
product provider for each income stream
product.
1 Type of investment/income
The income you receive from income stream
products must be included at question 70 and
question 74.
Name of organisation/company
Currency if not AUD
1 Name of product provider/SMSF/SAF
Your share
%
Type of income stream
Product reference number
If you have more than 1 other investment or source of
income, attach a separate sheet with details.
Your share
%
If you have more than 1 income stream, attach a separate
sheet with details.
EM164.170331
8 of 12
70 What was your gross income for the 8 weeks immediately
74 To determine your eligibility and calculate the amount you may
before the disaster?
be entitled to, in the 14 days following your loss of income, did
you receive, or are you entitled to receive, any income from any
source?
Gross income is the amount of income you earn before any
deductions are taken out (e.g. tax).
Include income from all sources, this includes income from
employment, income protection policies, shares, investments,
real estate income, superannuation, self-employment, holiday
pay, commission work etc.
Note: If you are a seasonal worker or your income is irregular,
call us on 180 22 66 to discuss your claim.
Gross income is the amount of income you earn before any
deductions are taken out (e.g. tax).
Include income from employment, income protection policies,
shares, investments, real estate income, superannuation,
self-employment, holiday pay, commission work etc.
Attach verification documents to confirm your income
(e.g. payslips, tax returns, profit and loss statements or
a letter from your employer).
Source of income
$
$
$
$
$
$
Total $
$
If you have more than 5 sources of income, attach a separate
sheet with details.
Total for 8 week period $
If you are eligible for this payment, you will be required to
report your fortnightly income.
If you have more than 7 sources of income, attach a separate
sheet with details.
71 If the disaster had not occurred, would your income have
continued at the same fortnightly amount in the 13 weeks
following your loss of income as it was before the disaster?
In some instances a person’s ongoing income may have
been expected to change. For example, due to a promotion
or change in job.
72 Did you expect your income to:
Tick ONE only
Decrease
Increase
73 How much did you expect to earn each fortnight on average for
the 13 weeks after the disaster?
$
per fortnight
You will only need to provide proof of the expected
increase in income (e.g. contract documents).
EM164.170331
Amount
$
$
Go to 74
Give details below
$
$
Go to next question
Yes
Source of income
$
No
Go to next question
You will need to provide proof of your income.
Amount
Yes
No
9 of 12
75 Do you have any accounts in banks, building societies, credit
76 Please read this before answering the following questions.
unions or church and charitable development funds?
You are not breaking the law if you do not give us your tax file
number, but if you do not provide it to us, or authorise us to
get it from the Australian Taxation Office, you may not be paid.
In giving us your tax file number in relation to this claim
you authorise us to use your tax file number for other social
security payments and services in future where necessary.
Do NOT include
• an account used exclusively for funding from the National
Disability Insurance Scheme
• bank accounts held in trust, or
• private companies.
No
Go to next question
Yes
Give details below
Have you given us your tax file number before?
You will need to attach bank statements for
the 8 weeks immediately before the disaster.
1 Name of bank, building society or credit union
No
Go to next question
Not sure
Go to next question
Go to 78
Yes
77 Do you have a tax file number?
Type of account
No
Please call us on 180 22 66.
Yes
Your tax file number
Branch number (BSB)
78 Please read this before answering the following question.
Disaster Recovery Allowance is a taxable payment. If your
only income for this financial year is the payment you are now
claiming, you may not have to pay any tax.
However, you may have to pay tax if you get any other income
this financial year, such as salary or wages.
If you think you will have to pay tax this year, you can ask us
to deduct tax instalments from your payment. You can change
this at any time.
If you are not sure how much tax to have taken out of your
payment, contact the Australian Taxation Office.
Account number (this may not be your card number)
Balance
Your share
%
$
2 Name of bank, building society or credit union
Type of account
Do you want tax taken out of your payment?
Branch number (BSB)
Account number (this may not be your card number)
No
Go to next question
Yes
Enter the amount OR percentage of tax you want
taken out from each payment.
Amount
Percentage (%)
(must be in whole dollars)
of taxable payment
$
Balance
$
Your share
%
If you have more than 2 accounts, attach a separate sheet
with details.
EM164.170331
10 of 12
.00 per payment OR
% per payment
79 Where do you want your payment made?
The bank, building society or credit union account must be in
your name. A joint account is acceptable.
Note: Payments cannot be made into an account used
exclusively for funding from the National Disability Insurance
Scheme.
82
IMPORTANT INFORMATION
Privacy and your personal information
Your personal information is protected by law (including
the Privacy Act 1988) and is collected by the Australian
Government Department of Human Services for the
assessment and administration of payments and services. This
information is required to process your application or claim.
Your information may be used by the department, or given
to other parties where you have agreed to that, or where it
is required or authorised by law (including for the purpose of
research or conducting investigations).
Relevant information may be given to Australian and State
Government Departments and organisations who are
involved in the joint administration of this disaster.
You can get more information about the way in which the
department will manage your personal information, including
our privacy policy, at humanservices.gov.au/privacy
Name of bank, building
society or credit union
Branch where the
account is held
Branch number (BSB)
Account number
(this may not be your
card number)
Account held in the name(s) of
83 Statement
80 Would you like a Centrelink social worker to contact you?
No
Go to next question
Yes
What number would you like to be contacted on?
()
81 Checklist
Please tick what information has been provided with the claim.
If verification documentation is not provided with this claim it
will need to be provided within 28 days.
All questions on this claim have been completed
Proof of identity that add up to the value of 50 points
(you may need to show us one document showing Proof of
Birth or Proof of Arrival in Australia, or any other approved
documents that add up to the value of 50 points,
for example, driver’s licence (40 points), bank card/
statement (40 points), Medicare card (20 points))
I declare that:
• the information I have provided in this form is complete and
correct.
• I have read the privacy notice above.
I understand that:
• giving false or misleading information is a serious offence.
• this payment is for people who have a loss of income as a
direct result of a disaster.
• the Australian Government Department of Human Services
can make relevant enquiries to make sure I receive the
correct entitlement.
• the Australian Government Department of Human Services
may request evidence to support any claims made on this
form.
• I must tell the Australian Government Department of
Human Services of any changes to this information or my
circumstances within 14 days.
• any overpayment will be recovered.
Your signature
Passport or visa details (if not an Australian citizen)
(if you answered No at question 29)
Copy of the most recent letter or statement from the
insurance policy
(if you answered Yes at question 61)
Date
Copy of your tax return for the previous year
(if you answered Yes at question 64)
//
The latest statement or document for each investment
(if you answered Yes at question 65, 66 or 67)
For how to return this form, see page 1.
A schedule from your product provider
for each income stream
(if you answered Yes at question 68)
Proof of income from investments or other sources
(if you answered Yes at question 69)
Proof of income before the disaster
(if required at question 70)
Proof of expected increased income
(if required at question 73)
Proof of income for the 14 days
following your loss of income
(if you answered Yes at question 74)
Copy of bank statements
(if required at question 75)
EM164.170331
11 of 12
Office Use Only
SO Logon ID
Identity type
Serial number
Issue date
Expiry date
//
State of issue
//
Country of issue
Identity type
Serial number
Issue date
Expiry date
//
State of issue
//
Country of issue
Identity type
Serial number
Issue date
Expiry date
//
State of issue
//
Country of issue
Identity type
Serial number
Issue date
Expiry date
//
State of issue
//
Country of issue
Original document sighted and returned
EM164.170331
12 of 12